Concurrent outbreaks of cholera and peripheral neuropathy associated with high mortality among persons internally displaced by a volcanic eruption.

BACKGROUND: In October 2004, Manam Island volcano in Papua New Guinea erupted, causing over 10 000 villagers to flee to internally displaced person (IDP) camps, including 550 from Dugulaba village. Following violence over land access in March 2010, the IDPs fled the camps, and four months later concurrent outbreaks of acute watery diarrhea and unusual neurological complaints were reported in this population. MATERIALS AND METHODS: A retrospective case-control study was conducted to identify the risk factors for peripheral neuropathy. Rectal swabs were collected from cases of acute watery diarrhea. Hair and serum metals and metalloids were analyzed by Inductively Coupled Plasma-Mass Spectrometry (ICP-MS). RESULTS: There were 17 deaths among the 550 village inhabitants during the outbreak period at a crude mortality rate 21-fold that of a humanitarian crisis. Vibrio cholerae O1 El Tor Ogawa was confirmed among the population. Access to community-level rehydration was crucial to mortality. Peripheral neuropathy was diagnosed among cases with neurological symptoms. A balanced diet was significantly protective against neuropathy. A dose-response relationship was seen between peripheral neuropathy and a decreasing number of micronutrient- rich foods in the diet. Deficiencies in copper, iron, selenium and zinc were identified among the cases of peripheral neuropathy. CONCLUSIONS: Cholera likely caused the mostly preventable excess mortality. Peripheral neuropathy was not caused by cholera, but cholera may worsen existing nutritional deficiencies. The peripheral neuropathy was likely caused by complex micronutrient deficiencies linked to non-diversified diets that potentially increased the vulnerability of this population, however a new zinc-associated neuropathy could not be ruled out. Reoccurrence can be prevented by addressing the root cause of displacement and ensuring access to arable land and timely resettlement.

Vibrio cholerae antimicrobial drug resistance, Papua New Guinea, 2009–2011

Cholera is an acute infectious disease caused by Vibrio cholerae . The disease occurs in a variety of forms ranging from sporadic cases to outbreaks that may transition to endemic disease. While cholera case management focuses on early, rapid rehydration, antimicrobial therapy can reduce the volume of diarrhoea, duration of carriage and symptoms and is frequently recommended for patients with severe dehydration.

Cholera risk factors, Papua New Guinea, 2010.

BACKGROUND: Cholera is newly emergent in Papua New Guinea but may soon become endemic. Identifying the risk factors for cholera provides evidence for targeted prevention and control measures. METHODS: We conducted a hospital-based case-control study to identify cholera risk factors. Using stool culture as the standard, we evaluated a cholera point of care test in the field. RESULTS: 176 participants were recruited: 54 cases and 122 controls. Independent risk factors for cholera were: being over 20 years of age (aOR 2.5; 95%CI 1.1, 5.4), defecating in the open air (or river) (aOR 4.5; 95% CI 1.4, 14.4) and knowing someone who travelled to a cholera affected area (aOR 4.1; 95%CI 1.6, 10.7); while the availability of soap for handwashing at home was protective (aOR 0.41; 95%CI 0.19, 0.87). Those reporting access to a piped water distribution system in the home were twice as likely to report the availability of soap for handwashing. The sensitivity and specificity of the rapid test were 72% (95% CI 47-90) and 71% (95%CI 44-90%). CONCLUSIONS: Improving population access to the piped water distribution system and sanitation will likely reduce transmission by enabling enhanced hygiene and limiting the contamination of water sources. The One step V. cholerae O1/O139 Antigen Test is of limited utility for clinical decision making in a hospital setting with access to traditional laboratory methods. Settlement dwellers and mobile populations of all age groups should be targeted for interventions in Papua New Guinea.

Are hard-to-reach populations being reached with immunization services? Findings from the 2005 Papua New Guinea national immunization coverage survey.

OBJECTIVE: To measure immunization coverage among children aged 12-23 months in Papua New Guinea (PNG) and to assess if and why there are differences between hard-to-reach and more accessible communities. METHODS: WHO cluster sampling methodology was employed to measure immunization coverage in PNG's four regions. Survey data were re-analyzed according to a local assessment of geographical accessibility indicated by census unit type: urban, rural and hard-to-reach. Census units were designated as hard-to-reach if they were five or more km from a health centre. FINDINGS: Nationwide coverage for most antigens falls below the national target of 80% although there are regional differences with Islands performing the best. Late doses are a major concern: just 4% were fully immunized with valid ("on time") doses by 1 year of age. Coverage was lower in both rural and remote communities: at 6 months 48% of children from urban units had received three valid doses of DTP-3 but only 16% in rural areas and 13% in hard-to-reach communities. Reasons for failure to immunize varied: 21% of mothers said their child was not immunized because distance, travel conditions or cost of transportation prevented access to local health centres; 27% cited a lack of knowledge or misconceptions about immunization; while 29% believed it was because of an issue with the health system. CONCLUSIONS: Throughout PNG there is an urgent need to increase immunization coverage and to ensure that children are immunized on time according to the schedule. Both coverage and timeliness of doses are worse for children living in hard-to-reach and rural areas. Achieving national immunization targets requires improvements in health service delivery, including outreach, especially for remote and rural communities, as well as greater community education and social mobilisation in support of immunization services.

A qualitative evaluation of the immunization program in Papua New Guinea.

OBJECTIVE: An in-depth evaluation of rural immunization services in Papua New Guinea was conducted to determine the reasons for poor immunization coverage, as well as to document the impact of recent efforts to strengthen the national immunization program. METHOD: A qualitative process was used to complement quantitative monitoring data. An interview process, based on open-ended questions, active listening and observation, was designed whereby a team of program supervisors collected information from rural health staff. The teams interviewed health staff in 30 health centres that were selected to provide examples of contrasting field situations. RESULTS: This qualitative review provided valuable detail about why immunization services were failing, encompassing locally specific weaknesses, such as logistic reasons for not conducting outreach, and generic systemic problems such as lack of access to funding. In addition, the information gathered provided details on local solutions developed by better-performing facilities. Both these aspects added significant value to quantitative measures of program performance (derived from national health information system data and analysis of supervision checklists). The review also captured a number of behavioural reasons that will need to be overcome before an improvement in the services can be expected. CONCLUSIONS AND IMPLICATIONS: This in-depth evaluation provided valuable information about problems in peripheral immunization clinics and identified local solutions. The high level of detail collected will be important for planning future strengthening of the health system. The study modelled a supportive form of supervision with the potential to improve outcomes from future supervisory visits. Some of the major barriers to improved immunization were locally specific organizational issues, as well as complex human problems. While some issues can be remedied through further strengthening of immunization systems, others lack easy, rapid solutions.